FEBRASGO POSITION STATEMENT Surgical management of postpartum hemorrhage Number 4 - October 2020 DOI: https://doi.org/10.1055/s-0040-1719159

The National Specialty Commission for Obstetric Emergencies of the Brazilian Federation of Gynecology and Associations (FEBRASGO) endorses to this document. The content production is based on scientific studies on a thematic proposal and the findings presented contribute to clinical practice.

Key-points: • Postpartum hemorrhage is the world’s leading cause of peripartum , even among women with a desire for future fertility. • Vascular ligation and uterine compression sutures must precede hysterectomy in the surgical treatment of postpartum hemorrhage. • The main technique of vascular ligation is bilateral uterine artery occlusion, although progressive devascular- ization techniques may optimize the surgical control of postpartum hemorrhage. • Uterine compression sutures are heterogeneous and the choice of technique to be applied must correlate with the hemorrhage etiology and the topography of the hemorrhagic focus. • The combination of uterine compression suture and vascular ligation increases the effectiveness of surgical treatment of postpartum hemorrhage. • Surgical techniques for controlling postpartum hemorrhage should be used immediately after failure of drug therapy, preferably within the “golden hour”. • All pregnant women with previa and previous cesarean section must have assisted birth in a tertiary service. • Damage control surgery is indicated when the patient with postpartum hemorrhage is already in the lethal triad and definitive interruption of was not possible or requires excessive time.

Recommendations: • In the surgical treatment of postpartum hemorrhage, when choosing vascular ligation and/or uterine com- pression sutures, the technique option must correlate with the topography of the hemorrhagic focus and the surgeon’s skill and experience. • If occurs during cesarean section and drug therapy fails, uterine compression sutures of B-Lynch and Hayman and/or bilateral ligation of the ascending branches of the uterine arteries are excellent surgical options. • In hemorrhage from placenta accreta that affects the uterine body, the Cho compression suture is an excellent surgical option. In placenta accreta of the uterine segment, both the Cho compression suture and low selective vascular ligations show excellent results in hemorrhagic control. • If surgical techniques for uterine preservation fail, hysterectomy is indicated and should be performed as early as possible, before is installed. Unless there is concomitant infection or the hemorrhagic etiology is an invasive central placenta previa, subtotal hysterectomy should be preferred. • The spectrum of placenta accreta in its previous increta and percreta varieties can be treated by means of hys- terectomy or uteroplacental segmental excision followed by restoration of the uterine anatomy. Hysterotomy and fetal extraction should be performed outside the invaded uterine area, usually in the uterine fundus. Vascular neoformation must be carefully and selectively ligated and hysterectomy must be performed with the placenta in situ. In the face of bladder invasion by the placenta, partial cystectomy and/or reimplantation of the ureters may be necessary. • In damage control surgery, the incisions must be large to facilitate technical execution. Open pelvic packing techniques with drainage reduce intestinal fistulas and increase the rate of primary closure. In patients under- going total hysterectomy, damage control can be achieved through closed packing by adapting an intrauterine balloon in the pelvis. • Skill training programs and simulations should be implemented in order to optimize the safety of care teams when applying surgical techniques to control postpartum hemorrhage.

FEBRASGO POSITION STATEMENT 679 Surgical management of postpartum hemorrhage

Background Postpartum hemorrhage (PPH) is the world’s leading cause of peripartum hysterectomy, even among wom- en with a desire for future fertility.(1) The main etiolo- gies are uterine atony, birth canal trauma, ovarian tis- sue retention and coagulation disorders. Uterine atony is the etiology with the highest incidence and placenta accreta is the one with the highest lethality. The pla- centa accreta spectrum shows its higher incidence that correlates with the contemporary increase in cesarean section rates. Undoubtedly, the placenta percreta is the Source: Illustration by Felipe Lage Starling (authorized). etiology of PPH that imposes greater surgical difficulty, Figure 1. Sagittal scheme of the division of S1 and S2 genital (2) especially when neighboring organs are affected. vascular regions In recent decades, several techniques have been developed to preserve the in PPH. Vascular liga- tion (VL), uterine compression suture (UCS), intrauterine towards the pubic bone, visualizing, palpating and li- balloons (IUBs), arterial embolization (AE) and intravas- gating the ascending branches of the uterine arter- cular balloons stand out. When well applied, surgical ies in their path in the posterior wall of the uterus. In techniques (VL and UCS) can provide faster hemorrhagic addition, it is complemented by the occlusion of ute- control and potentially preserve fertility.(3) ro-ovarian connections in the mesosalpinx.(7) In the tri- ple ligation of Tsirulnikov, in addition to the sutures de- When and how to apply surgical scribed above, sutures in the round ligament are added techniques for uterine preservation? by obstructing the flow of the round ligament arteries. Vascular ligation and UCSs are surgical techniques In step-by-step ligation techniques, sutures are pro- for controlling PPH that provide uterine preservation, gressively applied at 10-minute intervals. The hemor- and may or may not be applied in combination. The rhagic control after the application of a certain step is main indication for these techniques is uterine atony what determines the interruption in the application of with failure of drug therapy, especially during caesar- sutures. In the AbdRabbo technique, the sutures are ean section. Other indications include placenta ac- progressively applied to the ascending branches of the creta, after repositioning the uterus uterine arteries, to cervicouterine pedicles and to the and that can be preserved. These tech- ovarian arteries (infundibulopelvic ligaments). In the niques stand out for their low cost, fast learning curves, Morel technique, sutures are progressively applied to high percentage of success in hemorrhagic control, fer- the ascending branches of the uterine arteries, round tility preservation, and for avoiding the additional loss ligament arteries, utero-ovarian connections in the of two or more liters of linked to hysterectomy. mesosalpinx and cervicouterine pedicles (Figure 2).(8) Therefore, they are indicated prior to hysterectomy.(4) In the presence of invasive placenta previa, low The chosen technique must correlate with the to- selective ligations applied in region S2 with the use of pography of the hemorrhagic focus, since the genital suture passer are the ideal techniques for hemorrhag- vascular region S1 (uterine fundus and body) is irrigated ic control from vascular neoformation associated with by the uterine and ovarian arteries, while region S2 (seg- accretism.(5) As the ligation of the internal iliac arteries ment and ) receives blood supply from the internal (hypogastric) is performed far from the uterus and its pudendal, inferior vesical and middle, upper and lower annexes, it is less efficient than the other techniques vaginal arteries (Figure 1). Another important criteri- when used alone. Its most accurate indications in PPH on when choosing the technique is the surgeon’s skill, are severe lacerations of the birth canal and as a sup- knowledge and experience with the techniques.(5) porting procedure in the control of damage in patients The main VL technique is the bilateral uterine ar- already hysterectomized and in coagulopathy.(8,9) In tery occlusion (O’Leary technique). Bilateral sutures are association with other uterine preservation techniques done in the ascending branches of the uterine arteries. (IUB and UCS), this technique reduces hysterectomy Alternatively, “high” ligations can be added by using rates.(10) sutures in the utero-ovarian connections bilaterally Uterine compression sutures provide mechanical located in the mesosalpinx.(6) This technique is excel- compression in the uterine vascular sinus with simul- lent for uterine atony of the genital vascular region S1, taneous occlusion or not of the uterine arteries and good for S1 accretism, but inefficient for hemorrhag- other points of genital irrigation. The techniques are es in region S2. Very similar to the O’Leary technique, heterogeneous and what differentiates them is the the Posadas technique consists of flexing the uterus figure in which the suture is applied, the number of

680 FEBRASGO POSITION STATEMENT Alves AL, Nagahama G, Nozaki AM

of the uterine cavity and can be selectively applied to hemorrhagic topographies. The Hayman’s technique, on the other hand, has a mixed action mechanism, with compression of the uterine fundus on the seg- ment, associated or not with the obliteration of the segmental uterine cavity. After exteriorization of the uterus, two loops are applied to the uterine segment in the anteroposterior direction, each at a 3-4 cm distance from the lateral border of the uterus, end- ing with the knots in the uterine fundus.(11) Thus, the B-Lynch suture is excellent for uterine atony in the S1 region, good for accretion in S1 and ineffective for the S2 region. The Cho’s technique is good for uterine at- ony in S1 and excellent for accretism both in S1 and S2. The Hayman suture is an excellent option for uter- ine atony in S1 and good for accretism both in S1 and S2 (Figure 3). The effectiveness of UCSs increases when they are associated with VL.(12) A simple and efficient option is to associate bilateral ligation of the ascending branches of the uterine arteries with Hayman’s upper vertical com- Source: Illustrations by Felipe Lage Starling (authorized). pressive loops.(13) This strategy provides an association Upper left: bilateral ligation of the ascending branches of uterine arteries and utero-ovarian connections in the mesosalpinx (O’Leary technique); upper of techniques performed with only four needle passag- right: Tsirulnikov’s triple ligation (1 - ascending branch of the uterine artery; es in the uterus and is highly effective for the hemor- 2 - round ligament artery; 3 - utero-ovarian connections in the mesosalpinx); lower left: step-by-step AbdRabbo ligation (1 - ascending branch of the rhagic control of uterine atony and accretism in the S1 uterine artery; 2 - cervicouterine pedicle; 3 - ovarian artery); lower right: region (Figure 4). Morel step-by-step ligation (1 - ascending branch of the uterine artery; 2 - round ligament artery; 3 - utero-ovarian connections in the mesosalpinx; 4 Another association that optimizes hemorrhagic - cervicouterine pedicle). control is the “uterine sandwich” technique, in which the Figure 2. Vascular ligation techniques UCS is associated with uterine balloon tamponade. In this situation, the balloon is inserted through the hysterotomy vertical and/or horizontal suture sets and the pene- and the suture is applied under direct vision, preventing tration/occlusion or not of the uterine cavity. To pre- the needle from passing through the balloon. The balloon dict the success of the technique, the uterus must be infusion should be limited to only 100 mL of saline and compressed bimanually before the sutures are ap- performed at the end of the surgery, after closing the UCS plied, while the vaginal blood loss is checked simul- and laparorrhaphy.(14) taneously. The main UCSs are those of B-Lynch, Cho In order to prevent associated complications, the and Hayman. The mechanism of action of the B-Lynch current trend is towards the development of remov- suture is the compression of the uterine fundus on the able UCSs.(15,16) The main techniques already described segment, simulating the effect of a uterine compres- are the Aboulfalah and Zhang USCs (removable B-Lynch sion maneuver. The Cho suture promotes obliteration and Hayman) (Figure 5).

Source: Illustrations by Felipe Lage Starling (authorized). Figure 3. B-Lynch, Cho and Hayman uterine compression sutures

FEBRASGO POSITION STATEMENT 681 Surgical management of postpartum hemorrhage

sence of a central placenta previa or infection, subtotal hysterectomy should be preferred.(2)

How to treat placenta accreta surgically? Every pregnant woman with placenta previa and prior cesarean section must have assisted birth in a tertiary service, because the treatment, especially of placenta percreta that invades neighboring organs (bladder, ab- dominal vessels), requires a multidisciplinary team.(18) The surgical approach must be properly planned (re- serve of blood components, definition of the anesthetic technique and laparotomy incision), performed by an experienced team and guided according to the invaded Source: Illustration by Felipe Lage Starling (authorized). genital vascular region (S1 or S2). Since placental blood Ligation of the ascending branches of the uterine artery and vertical loops of flow at gestational term is 600 to 700 mL/min, elective the uterine compression suture interruption between 35 and 38 weeks is consensus.(5,19) Figure 4. Technique of uterine devascularization and uterine Starting with spinal anesthesia until fetal extraction, compression suture then proceeding to general anesthesia is a good strategy The main complications related to VL and UCSs are in the face of prolonged surgical time often imposed by infections (pyometrium, endometritis and endomyo- the need for extensive dissection of vascular neoforma- metritis), ischemic partial necrosis, erosions, sulcus and tions. After wide laparotomy (longitudinal incisions may defects in the uterine wall, synechiae, hematometrium, be necessary) and adequate uterine exposure, hysterot- Asherman’s syndrome and uterine rupture in subse- omy and fetal extraction should be performed outside quent .(4) Both VLs and UCSs must be made the invaded uterine area. Thus, fundal hysterotomies only with absorbable thread sutures. Polyglecaprone should be preferred. After clamping and removal of is the suture material of choice, with polyglactin and the umbilical cord, hysterorrhaphy is performed with polydioxanone as second options. For the application the placenta in situ. The ureters and internal iliac ar- of some techniques, straight needles may be neces- teries (hypogastric) should be located and the surgical sary.(17) technique defined. The exeresis by segmental excision followed by restoration of the uterine anatomy may be When and how to perform preferable to hysterectomy. Both require experience and hysterectomy in uterine atony? dexterity from the surgeon to perform the low selective Currently, hysterectomy should be the last stage of ligation (using suture passer) of vascular neoformations, the surgical approach to PPH due to uterine atony and especially in the uterine segment. In hysterectomy per- performed without delay before the installation of the formed by means of high vascularization and uterovesi- lethal triad (coagulopathy, acidosis and hypothermia). cal adhesion, mobilization and bladder dissection (Pelosi Since the removal of the puerperal uterus imposes an by-pass) performed in zones of adhesion are useful in additional loss of two to three liters of blood, its late per- preventing urinary tract injuries (Figures 6, 7, 8 and 9). formance can worsen the hemorrhagic shock. In the ab- In the face of bladder invasion by the placenta, one of

Source: Illustrations by Felipe Lage Starling (authorized). 1 – Aboulfalah; 2 – Removable B-Lynch by Zhang; 3 – Removable Hayman by Zhang. Figure 5. Removable uterine compression sutures

682 FEBRASGO POSITION STATEMENT Alves AL, Nagahama G, Nozaki AM

Figure 6. Steps of the cesarean-hysterectomy technique in the surgical treatment of placenta accreta

Exposure of vascular neoformations present in vesicouterine reflection by means of traction with Allis forceps. Double ligation performed with a suture passer. Figure 7. Low selective ligation of vascular neoformations present in the uterine segment in the surgical treatment of placenta accreta

Left: exeresis of the uterine segment affected by invasion of placental cotyledons and ovular membranes. Center and right: final result of restoration After performing the low selective ligation of vascular neoformations, of the uterine anatomy with hysterorrhaphy in the uterine fundus and suture mobilization and blunt dissection of the vesicouterine space are performed. between the uterine body and the lower residual portion of the segment. Figure 8. Mobilization and bladder dissection (Pelosi by-pass) Figure 9. Exeresis with segmental uteroplacental excision followed performed in the areas of vesicouterine adhesions in the surgical by restoration of uterine anatomy in the surgical treatment of treatment of placenta accreta placenta accreta the options is to perform partial cystectomy and “one- is the application of segmental UCSs. The most suitable piece” hysterectomy (Pelosi technique).(20) As an alterna- techniques for this purpose are the Cho UCSs (adapted tive to partial cystectomy, and especially in the face of in- by Palacios-Jaraquemada),(5,19) Dedes and Zioga or the vasion of the bladder trigone (rare), embolization of the transverse segmental figure-of-8 UCS (Figure 10). The uterine and internal pudendal arteries is a good option strategies described above offer the advantage of one- for sites with this technical availability. Eventually, ure- step surgical resolution. teral reimplantation is necessary. An alternative for the In exceptional situations, such as in extrauterine control of hemorrhage in the genital vascular region S2 placental implantations (in large vessels or adjacent

FEBRASGO POSITION STATEMENT 683 Surgical management of postpartum hemorrhage

Figure 10. Cho uterine compression sutures (adapted by Palacios-Jaraquemada),(19) Dedes and Zioga and transverse segmental figure-of-8 organs), maintaining the placenta in situ associated or must be adapted to the suction system at a negative not with methotrexate or arterial embolization may be pressure between -100 and -150 mmHg.(22,23) the safest resource.(19) In patients undergoing total hysterectomy, dam- In the face of prenatal diagnostic failure followed by age control can be achieved through closed packing. In perioperative diagnosis in non-ideal surgical conditions this technique, an intrauterine balloon is inserted into (lack of experience of the team and/or blood compo- the pelvis and its axis is directed to the vaginal cavity, nents), the surgical procedure must be restricted to hys- before the approach to the vaginal dome. After laparo- terotomy and fetal extraction outside the invaded uter- rraphy and the balloon infusion, a weight is connected ine area, followed by hysterorrhaphy with the placenta in to its axis and adapted to the bedside in order to opti- situ and laparorraphy. In these situations, the definitive mize pelvic compression (Figure 11). In this technical re-approach (hysterectomy or excision with uteropla- option, surgical re-approach is not necessary. After cental segmental exeresis followed by restoration of the physiological restoration, the balloon is deflated and uterine anatomy) is performed after the reorganization removed through the .(24,25) of the care conditions (two step).(5,19)

When and how to perform damage control surgery? Damage control surgery (pelvic packing and laparosto- my, with or without concomitant ligation of the internal iliac arteries) is indicated when definitive bleeding con- trol was not possible or when it demands excessive time and the patient is already in the lethal triad. The goal is to temporarily control the hemorrhagic focus and allow Left: open pelvic packing; the red arrow indicates aspiration; the blue arrow indicates the protective pouch of the pelvic pack made with compresses. the restoration of the patient’s physiology in intensive Right: closed packing with an intrauterine balloon adapted to the pelvis. care. The surgery is temporary. The control of the re- Figure 11. Pelvic packing damage control surgery maining hemorrhagic foci and the permanent laparor- rhaphy should be performed two to five days later.(20,21) Still in the context of care to puerperal women in Open pelvic packing techniques with drainage critical situation due to severe PPH, such as imminent reduce intestinal fistulas and increase the rate of pri- cardiopulmonary arrest and extra-hospital care, the ex- mary closure. Longitudinal incisions may be necessary ternal manual compression of the infrarenal aorta can for good technical execution. A good option for open be performed as a life-saving maneuver. Compression packing (laparorrhaphy) includes the insertion of 7 to should be temporary (maximum 90 minutes) with the 10 compresses in the pelvis and a fenestrated pouch application of a force of approximately 45 kg and per- above the package that will not be sutured, being formed until the arrival of support and/or the start of loose and below the parietal peritoneum. Above this correction of coagulopathy and shock.(26) first bag, two compresses are allocated. Above these, Finally, the evolution of the HPP assistance flow- one or two drains, plus two compresses for top drain charts with incorporation of several more recent sur- protection are placed. The technique is completed gical idealization and evaluation techniques imposed with the insertion of a second, non-fenestrated pouch on care teams the need to acquire new skills and com- sutured directly to the skin. As alternative to this sec- petences. These can be obtained through skills train- ond pouch, an adherent dressing involving the entire ing programs and simulations aimed at optimizing the abdominal circumference can be applied. The drains safety and technical quality of the care teams.(27)

684 FEBRASGO POSITION STATEMENT Alves AL, Nagahama G, Nozaki AM

8. Morel O, Malartic C, Muhlstein J, Gayat E, Judlin P, Soyer P, et Final considerations al. Pelvic arterial ligations for severe post-partum hemorraghe. Since HPP is the major cause of maternal mortality Indications and techniques. J Visc Surg. 2011;148(2):e95-102. worldwide, health care teams’ ability to institute surgi- doi: 10.1016/j.jviscsurg.2011.02.002 cal treatment, preferably within the “golden hour”, be- 9. Sziller I, Hupuczi P, Papp Z. Hypogastric artery ligation for comes essential in the event of drug treatment failure. severe hemorrhage in obstetric patients. J Perinat Med. The contemporary development of invasive techniques 2007;35(3):187-92. doi: 10.1515/JPM.2007.049 that preserve the uterus and have high rates of success 10. Kaya B, Damarer Z, Daglar K, Unal O, Soliman A, Guralp O. Is there yet a role for ligation in obstetric in hemorrhagic control has changed the sequencing hemorrhage with the current gain in popularity of other of surgical treatment for PPH. These techniques, in- uterus sparing techniques? J Matern Fetal Neonatal Med. cluding IUB, UCS, VL, AE and their associations must 2017;30(11):1325-32. doi: 10.1080/14767058.2016.1212333 precede hysterectomy and their choice must correlate 11. Palacios-Jaraquemada JM. Efficacy of surgical techniques with the mode of delivery, PPH etiology, topography of to control obstetric hemorrhage: analysis of 539 cases. the hemorrhagic focus and valuably, with the skill and Acta Obstet Gynecol Scand. 2011;90(9):1036-42. doi: experience of professionals. However, in view of the 10.1111/j.1600-0412.2011.01176.x failure of surgical techniques that preserve the uterus, 12. Kaya B, Tuten A, Daglar K, Onkun M, Sucu S, Dogan A, et al. B-Lynch uterine compression sutures in the conservative hysterectomy should be performed as early as possible, surgical management of uterine atony. Arch Gynecol Obstet. before the installation of coagulopathy. Hysterectomy 2015;291(5):1005-14. doi: 10.1007/s00404-014-3511-2 is also frequently required as a primary treatment in the 13. Alves ALL, Senra JC, São José CN, Ribeiro BR, Furtado RS, Silva LB, et face of the spectrum of placenta accreta, especially in al. Uterine desvascularization associated with compressive uterine increta and percreta varieties associated with unfavor- suture (UD-CUS) in surgical treatment of postpartum hemorrhage. able conditions for uteroplacental segmental exeresis Int J Gynecol Obstet. 2020;149(1):111-2. doi: 10.1002/ijgo.13081 and restoration of uterine anatomy. In these situations, 14. Yoong W, Ridout A, Memtsa M, Stavroulis A, Aref-Adib M, the complexity of the operative tactic and severity of Ramsay-Marcelle Z, et al. Application of uterine compression suture in association with intrauterine balloon tamponade the risks demand adequate surgical conditions and a (‘uterine sandwich’) for postpartum hemorrhage. Acta Obstet qualified and experienced multidisciplinary team. Since Gynecol Scand. 2012;91(1):147-51. doi: 10.1111/j.1600- it is a cause of high lethality, high incidence and com- 0412.2011.01153.x plex and specialized surgical treatment, its current im- 15. Aboulfalah A, Fakhir B, Kaddour YAB, Asmouki H, Soummani A. pact on the planning and reorganization of care teams A new removable uterine compression by a brace suture in the is significant. management of severe postpartum hemorrhage. Front Surg. 2014;1:43. doi: 10.3389/fsurg.2014.00043 16. Zhang ZW, Liu CY, Yu N, Guo W. Removable uterine compression References sutures for postpartum haemorrhage. BJOG. 2015;122(3):429- 1. Bodelon C, Bernabe-Ortiz A, Schiff MA, Reed SD. 33. doi: 10.1111/1471-0528.13025 Factors associated with peripartum hysterectomy. Obstet Gynecol. 2009;114(1):115-23. doi: 10.1097/ 17. Mallappa Saroja CS, Nankani A, El-Hamamy E. Uterine AOG.0b013e3181a81cdd compression sutures, an update: review of efficacy, safety and complications of B-Lynch suture and other uterine compression 2. American College of Obstetricians and Gynecologists. techniques for postpartum haemorrhage. Arch Gynecol Obstet. Committee on Practice Bulletins-Obstetrics. Practice 2010;281(4):581-8. doi: 10.1007/s00404-009-1249-z Bulletin No 183: postpartum hemorrhage. Obstet Gynecol. 2017;130(4):e168-86. doi: 10.1097/AOG.0000000000002351 18. Clark SL, Hankins GDV. Preventing : 10 clinical diamonds. Obstet Gynecol. 2012;119(2 Pt 1):360-4. doi: 3. Chandraharan E, Arulkumaran S. Surgical aspects of 10.1097/AOG.0b013e3182411907 postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2008;22(6):1089-102. doi: 10.1016/j.bpobgyn.2008.08.001 19. Palacios-Jaraquemada JM. Caesarean section in cases of and accreta. Best Pract Res Clin Obstet Gynaecol. 4. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. 2013;27(2):221-32. doi: 10.1016/j.bpobgyn.2012.10.003 Systematic review of conservative management of postpartum haemorrhage: what to do when medical treatment fails. 20. Pelosi MA 3rd, Pelosi MA. Modified cesarean hysterectomy for Obstet Gynecol Surv. 2007;62(8):540-7. doi: 10.1097/01. placenta previa percreta with bladder invasion: retrovesical ogx.0000271137.81361.93 lower uterine segment bypass. Obstet Gynecol. 1999;93(5 Pt 2):830-3. doi: 10.1016/s0029-7844(98)00426-8 5. Palacios-Jaraquemada JM. Surgical anatomy. In: Palacios- Jaraquemada JM. Placental adhesive disorders. Berlin: De 21. Carvajal JA, Ramos I, Kusanovic JP, Escobar MF. Damage-control Gruyter; 2012. p. 43-78. resuscitation in obstetrics. J Matern Fetal Neonatal Med. 2020 Feb 26. doi: 10.1080/14767058.2020.1730800. [ahead of print] 6. Moise KJ Jr, Belfort MA. Damage control for the obstetric patient. Surg Clin North Am. 1997;77(4):835-52. doi: 10.1016/ 22. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns s0039-6109(05)70588-0 RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma. 2000;48(2):201- 7. Posadas-Nava A, Moreno-Santillán AA, Celis-González C, 7. doi: 10.1097/00005373-200002000-00001 Cruz-Martínez E. Control efectivo de la hemorragia obstétrica posparto mediante desarterialización selectiva uterina. 23. Rezende-Neto JB, Cunha-Melo JR, Andrade MV. Cobertura Descripción de la técnica Posadas. Ginecol Obstet Mex. temporária da cavidade abdominal com curativo a vácuo. 2016;84(12):808-13. Rev Col Bras Cir. 2007;34(5):336-9. doi: 10.1590/S0100- 69912007000500011

FEBRASGO POSITION STATEMENT 685 Surgical management of postpartum hemorrhage

24. Waks A, Tabsh K, Tabsh K, Afshar Y. Balloon uterine tamponade device after peripartum histerectomy for morbidly adherent Álvaro Luiz Lage Alves1 placenta. Obstet Gynecol. 2018;132(3):643-6. doi: 10.1097/ 1Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG, AOG. 0000000000002792 Brazil.

25. Charoenkwan K. Effective use of the Bakri postpartum 2 balloon for posthysterectomy pelvic floor hemorrhage. Am Gilberto Nagahama 2Maternidade Escola Vila Nova Cachoeirinha, São Paulo, SP, Brazil. J Obstet Gynecol. 2014;210(6):586.e1-e3. doi: 10.1016/j. ajog.2014.03.068 Alexandre Massao Nozaki3 26. Soltan MH, Faragallah MF, Mosabah MH, Al-Adawy AR. External 3Hospital Maternidade Interlagos, São Paulo, SP, Brazil. aortic compression device: the first aid for postpartum Conflict of interest: none to declare. hemorrhage control. J Obstet Gynaecol Res. 2009;35(3):453-8. doi: 10.1111/j.1447-0756.2008.00975.x National Specialty Commission for Obstetric Emergencies of the 27. Ghaem-Maghami S, Brockbank E, Bridges J. Survey of surgical Brazilian Federation of Gynecology and Obstetrics Associations experience during training in obstetrics and gynaecology (FEBRASGO) in the UK. J Obstet Gynaecol. 2006;26(4):297-301. doi: President: 10.1080/01443610600594740 Álvaro Luiz Lage Alves Members: Gabriel Costa Osanan Samira El Maerrawi Tebecherane Haddad Adriana Amorim Francisco Alexandre Massao Nozaki Brena Carvalho Pinto de Melo Breno José Acauan Filho Carla Betina Andreucci Polido Eduardo Cordioli Frederico José Amedée Peret Gilberto Nagahama Laíses Braga Vieira Lucas Barbosa da Silva Marcelo Guimarães Rodrigues Rodrigo Dias Nunes Roxana Knobel

686 FEBRASGO POSITION STATEMENT